|
CYCLOBENZAPRINE 10 MG PO TABLET
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: AlohaCare Medicaid |
$0.60
|
| Rate for Payer: AlohaCare Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Devoted Health Medicare |
$1.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Humana Medicare |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.08
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
CYCLOBENZAPRINE 5 MG PO TABLET
|
Facility
|
IP
|
$9.06
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Cash Price |
$5.89
|
| Rate for Payer: Health Management Network Commercial |
$7.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.15
|
| Rate for Payer: MDX Hawaii PPO |
$8.79
|
|
|
CYCLOBENZAPRINE 5 MG PO TABLET
|
Facility
|
OP
|
$9.06
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: AlohaCare Medicaid |
$4.53
|
| Rate for Payer: AlohaCare Medicare |
$8.15
|
| Rate for Payer: Cash Price |
$5.89
|
| Rate for Payer: Devoted Health Medicare |
$8.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.61
|
| Rate for Payer: Health Management Network Commercial |
$7.70
|
| Rate for Payer: Humana Medicare |
$8.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.15
|
| Rate for Payer: MDX Hawaii PPO |
$8.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.15
|
| Rate for Payer: University Health Alliance Commercial |
$6.60
|
|
|
CYCLOPENTOLATE 1 % OPHT DROP
|
Facility
|
OP
|
$164.69
|
|
|
Service Code
|
NDC 00065039602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.34 |
| Max. Negotiated Rate |
$163.04 |
| Rate for Payer: AlohaCare Medicaid |
$82.34
|
| Rate for Payer: AlohaCare Medicare |
$148.22
|
| Rate for Payer: Cash Price |
$107.05
|
| Rate for Payer: Devoted Health Medicare |
$163.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$156.46
|
| Rate for Payer: Health Management Network Commercial |
$139.99
|
| Rate for Payer: Humana Medicare |
$148.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$148.22
|
| Rate for Payer: MDX Hawaii PPO |
$159.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$148.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.22
|
| Rate for Payer: University Health Alliance Commercial |
$120.04
|
|
|
CYCLOPENTOLATE 1 % OPHT DROP
|
Facility
|
IP
|
$164.69
|
|
|
Service Code
|
NDC 00065039602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.99 |
| Max. Negotiated Rate |
$159.75 |
| Rate for Payer: Cash Price |
$107.05
|
| Rate for Payer: Health Management Network Commercial |
$139.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.22
|
| Rate for Payer: MDX Hawaii PPO |
$159.75
|
|
|
CYPROHEPTADINE 4 MG PO TABLET
|
Facility
|
IP
|
$5.89
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.01 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Health Management Network Commercial |
$5.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.30
|
| Rate for Payer: MDX Hawaii PPO |
$5.71
|
|
|
CYPROHEPTADINE 4 MG PO TABLET
|
Facility
|
OP
|
$5.89
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: AlohaCare Medicaid |
$2.94
|
| Rate for Payer: AlohaCare Medicare |
$5.30
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Devoted Health Medicare |
$5.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.60
|
| Rate for Payer: Health Management Network Commercial |
$5.01
|
| Rate for Payer: Humana Medicare |
$5.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.30
|
| Rate for Payer: MDX Hawaii PPO |
$5.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.30
|
| Rate for Payer: University Health Alliance Commercial |
$4.29
|
|
|
D5 %-0.45 % SODIUM CHLORIDE IV SOLP
|
Facility
|
OP
|
$16.56
|
|
|
Service Code
|
NDC 00264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: AlohaCare Medicaid |
$8.28
|
| Rate for Payer: AlohaCare Medicare |
$14.90
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Devoted Health Medicare |
$16.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.73
|
| Rate for Payer: Health Management Network Commercial |
$14.08
|
| Rate for Payer: Humana Medicare |
$14.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.90
|
| Rate for Payer: MDX Hawaii PPO |
$16.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.90
|
| Rate for Payer: University Health Alliance Commercial |
$12.07
|
|
|
D5 %-0.45 % SODIUM CHLORIDE IV SOLP
|
Facility
|
IP
|
$16.56
|
|
|
Service Code
|
NDC 00264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$16.06 |
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Health Management Network Commercial |
$14.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.90
|
| Rate for Payer: MDX Hawaii PPO |
$16.06
|
|
|
D5-1/2NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX
|
Facility
|
IP
|
$38.62
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$37.46 |
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Health Management Network Commercial |
$32.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.76
|
| Rate for Payer: MDX Hawaii PPO |
$37.46
|
|
|
D5-1/2NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX
|
Facility
|
OP
|
$38.62
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$38.23 |
| Rate for Payer: AlohaCare Medicaid |
$19.31
|
| Rate for Payer: AlohaCare Medicare |
$34.76
|
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Devoted Health Medicare |
$38.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.69
|
| Rate for Payer: Health Management Network Commercial |
$32.83
|
| Rate for Payer: Humana Medicare |
$34.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.76
|
| Rate for Payer: MDX Hawaii PPO |
$37.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.76
|
| Rate for Payer: University Health Alliance Commercial |
$28.15
|
|
|
D5 % AND 0.9 % SODIUM CHLORIDE IV SOLP
|
Facility
|
IP
|
$22.08
|
|
|
Service Code
|
HCPCS J7042
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.87
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
|
|
D5 % AND 0.9 % SODIUM CHLORIDE IV SOLP
|
Facility
|
OP
|
$22.08
|
|
|
Service Code
|
HCPCS J7042
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$21.86 |
| Rate for Payer: AlohaCare Medicaid |
$11.04
|
| Rate for Payer: AlohaCare Medicare |
$19.87
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Devoted Health Medicare |
$21.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.98
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: Humana Medicare |
$19.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.87
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.87
|
| Rate for Payer: University Health Alliance Commercial |
$16.09
|
|
|
D5LR 1000 ML WITH KCL 20MEQ/L IV PREMIX
|
Facility
|
OP
|
$63.54
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$62.90 |
| Rate for Payer: AlohaCare Medicaid |
$31.77
|
| Rate for Payer: AlohaCare Medicare |
$57.19
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Devoted Health Medicare |
$62.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.36
|
| Rate for Payer: Health Management Network Commercial |
$54.01
|
| Rate for Payer: Humana Medicare |
$57.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.19
|
| Rate for Payer: MDX Hawaii PPO |
$61.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.19
|
| Rate for Payer: University Health Alliance Commercial |
$46.31
|
|
|
D5LR 1000 ML WITH KCL 20MEQ/L IV PREMIX
|
Facility
|
IP
|
$63.54
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.01 |
| Max. Negotiated Rate |
$61.63 |
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Health Management Network Commercial |
$54.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.19
|
| Rate for Payer: MDX Hawaii PPO |
$61.63
|
|
|
D5NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX
|
Facility
|
IP
|
$38.62
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$37.46 |
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Health Management Network Commercial |
$54.01
|
| Rate for Payer: Health Management Network Commercial |
$32.83
|
| Rate for Payer: Health Management Network Commercial |
$45.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.19
|
| Rate for Payer: MDX Hawaii PPO |
$61.63
|
| Rate for Payer: MDX Hawaii PPO |
$37.46
|
| Rate for Payer: MDX Hawaii PPO |
$51.54
|
|
|
D5NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX
|
Facility
|
OP
|
$53.13
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$52.60 |
| Rate for Payer: AlohaCare Medicaid |
$26.57
|
| Rate for Payer: AlohaCare Medicaid |
$31.77
|
| Rate for Payer: AlohaCare Medicaid |
$19.31
|
| Rate for Payer: AlohaCare Medicare |
$57.19
|
| Rate for Payer: AlohaCare Medicare |
$34.76
|
| Rate for Payer: AlohaCare Medicare |
$47.82
|
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Devoted Health Medicare |
$62.90
|
| Rate for Payer: Devoted Health Medicare |
$52.60
|
| Rate for Payer: Devoted Health Medicare |
$38.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.47
|
| Rate for Payer: Health Management Network Commercial |
$32.83
|
| Rate for Payer: Health Management Network Commercial |
$45.16
|
| Rate for Payer: Health Management Network Commercial |
$54.01
|
| Rate for Payer: Humana Medicare |
$47.82
|
| Rate for Payer: Humana Medicare |
$34.76
|
| Rate for Payer: Humana Medicare |
$57.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.19
|
| Rate for Payer: MDX Hawaii PPO |
$61.63
|
| Rate for Payer: MDX Hawaii PPO |
$37.46
|
| Rate for Payer: MDX Hawaii PPO |
$51.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.82
|
| Rate for Payer: University Health Alliance Commercial |
$46.31
|
| Rate for Payer: University Health Alliance Commercial |
$38.73
|
| Rate for Payer: University Health Alliance Commercial |
$28.15
|
|
|
DALBAVANCIN 500 MG IV SOLN
|
Facility
|
IP
|
$3,253.36
|
|
|
Service Code
|
HCPCS J0875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,765.36 |
| Max. Negotiated Rate |
$3,155.76 |
| Rate for Payer: Cash Price |
$2,114.68
|
| Rate for Payer: Health Management Network Commercial |
$2,765.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,928.02
|
| Rate for Payer: MDX Hawaii PPO |
$3,155.76
|
|
|
DALBAVANCIN 500 MG IV SOLN
|
Facility
|
OP
|
$3,253.36
|
|
|
Service Code
|
HCPCS J0875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.55 |
| Max. Negotiated Rate |
$3,220.83 |
| Rate for Payer: AlohaCare Medicaid |
$1,626.68
|
| Rate for Payer: AlohaCare Medicare |
$2,928.02
|
| Rate for Payer: Cash Price |
$2,114.68
|
| Rate for Payer: Cash Price |
$2,114.68
|
| Rate for Payer: Devoted Health Medicare |
$3,220.83
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.55
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,928.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$15.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,090.69
|
| Rate for Payer: Health Management Network Commercial |
$2,765.36
|
| Rate for Payer: Humana Medicare |
$2,928.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,928.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,659.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,928.02
|
| Rate for Payer: MDX Hawaii PPO |
$3,155.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,928.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,928.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,952.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,928.02
|
| Rate for Payer: University Health Alliance Commercial |
$2,371.37
|
|
|
DANTROLENE 25 MG PO CAP
|
Facility
|
IP
|
$5.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Cash Price |
$3.46
|
| Rate for Payer: Health Management Network Commercial |
$4.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.79
|
| Rate for Payer: MDX Hawaii PPO |
$5.16
|
|
|
DANTROLENE 25 MG PO CAP
|
Facility
|
OP
|
$5.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: AlohaCare Medicaid |
$2.66
|
| Rate for Payer: AlohaCare Medicare |
$4.79
|
| Rate for Payer: Cash Price |
$3.46
|
| Rate for Payer: Devoted Health Medicare |
$5.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.05
|
| Rate for Payer: Health Management Network Commercial |
$4.52
|
| Rate for Payer: Humana Medicare |
$4.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.79
|
| Rate for Payer: MDX Hawaii PPO |
$5.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.79
|
| Rate for Payer: University Health Alliance Commercial |
$3.88
|
|
|
DAPSONE 25 MG PO TABLET
|
Facility
|
OP
|
$13.61
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$13.47 |
| Rate for Payer: AlohaCare Medicaid |
$6.80
|
| Rate for Payer: AlohaCare Medicare |
$12.25
|
| Rate for Payer: Cash Price |
$8.85
|
| Rate for Payer: Devoted Health Medicare |
$13.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.93
|
| Rate for Payer: Health Management Network Commercial |
$11.57
|
| Rate for Payer: Humana Medicare |
$12.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.25
|
| Rate for Payer: MDX Hawaii PPO |
$13.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.25
|
| Rate for Payer: University Health Alliance Commercial |
$9.92
|
|
|
DAPSONE 25 MG PO TABLET
|
Facility
|
IP
|
$13.61
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$13.20 |
| Rate for Payer: Cash Price |
$8.85
|
| Rate for Payer: Health Management Network Commercial |
$11.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.25
|
| Rate for Payer: MDX Hawaii PPO |
$13.20
|
|
|
DAPTOMYCIN 500 MG IV RECON.SOLN. (MG/KG)
|
Facility
|
OP
|
$1,349.71
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1,336.21 |
| Rate for Payer: AlohaCare Medicaid |
$674.86
|
| Rate for Payer: AlohaCare Medicare |
$1,214.74
|
| Rate for Payer: Cash Price |
$877.31
|
| Rate for Payer: Cash Price |
$877.31
|
| Rate for Payer: Devoted Health Medicare |
$1,336.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,214.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,282.22
|
| Rate for Payer: Health Management Network Commercial |
$1,147.25
|
| Rate for Payer: Humana Medicare |
$1,214.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,214.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$688.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,214.74
|
| Rate for Payer: MDX Hawaii PPO |
$1,309.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,214.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,214.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$809.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,214.74
|
| Rate for Payer: University Health Alliance Commercial |
$983.80
|
|
|
DAPTOMYCIN 500 MG IV RECON.SOLN. (MG/KG)
|
Facility
|
IP
|
$1,349.71
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,147.25 |
| Max. Negotiated Rate |
$1,309.22 |
| Rate for Payer: Cash Price |
$877.31
|
| Rate for Payer: Health Management Network Commercial |
$1,147.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,214.74
|
| Rate for Payer: MDX Hawaii PPO |
$1,309.22
|
|
